Every year at least 100,000 Americans die undergoing inpatient surgical procedures. Wide variation in mortality rates across hospitals suggests substantial opportunities for improvement. Payers and professional organizations are hoping that checklists, pay for performance programs, and national outcomes registries will reduce rates of surgical complications and ultimately mortality. However, recent research suggests that high mortality and low mortality hospitals are distinguished less by their complication rates than by how successfully they recognize and manage complications once they occur. Thus, minimizing failure to rescue (i.e., death following a major complication) may be essential in efforts to reduce surgical mortality. Successful rescue hinges on early recognition and timely management of serious complications once they occur. Focusing on the clinical deterioration of patients during the early golden hours of decline may yield valuable insights into how some hospitals achieve exemplary outcomes. Unfortunately, previous work does not identify actionable insights into how hospitals can improve their rescue rates. A better understanding of how interactions and relationships within hospital micro-systems could be even more crucial to improving rescue through practical and effective interventions. To explore these issues, we propose a study designed to assess such factors and to develop and implement an intervention in Michigan hospitals aimed at improving overall safety culture, communication, and rescue rates. The specific research aims are (i) to develop an in-depth understanding of the key elements, such as teamwork and communication, necessary for complication rescue; (ii) to design an intervention that promotes key elements for improving rescue; and (iii) to pilot an intervention aimed at improving hospital rescue rates. This work will shed light on how healthcare organizations can be engaged to better sense, cope with, and respond to the unexpected and changing demands presented by clinically deteriorating post-surgical patients with life-threatening complications. This project will have direct, population-level impact to inform interventions aimed at reducing mortality in surgical patients in Michigan, and ultimately elsewhere. Results from this study will also inform large payer (including CMS) and regulators (particularly JCAHO) as they set incentives and standards for enhancing the safety of inpatient surgery in the United States. Further, the research project, highly experienced multidisciplinary mentorship team, and unparalleled research environment are ideally suited to address the career goals and educational needs of the candidate, Amir A. Ghaferi, MD, MS. The proposal includes a detailed educational plan with training that will be essential both for successful completion of this research and toward Dr. Ghaferi's career development. The training includes graduate level courses in organizational management, behavior, and theory, qualitative research methods, and implementation science. This career development award will lay the groundwork for Dr. Ghaferi to perform ongoing, innovative health services research, and to become an independent investigator and national leader in patient safety and quality improvement.